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Holistic care of complicated tuberculosis in healthcare settings with limited resources
  1. Trevor Duke1,2,3,
  2. Sharon Kasa Tom4,
  3. Harry Poka5,
  4. Henry Welch3,6
  1. 1 Centre for International Child Health, University of Melbourne, Parkville, Victoria, Australia
  2. 2 Intensive Care Unit, Royal Children’s Hospital, Parkville, Victoria, Australia
  3. 3 Discipline of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Moresby, Papua New Guinea
  4. 4 Department of Paediatrics, Wabag General Hospital, Wabag, Papua New Guinea
  5. 5 Department of Paediatrics, Sir Joseph Nombri Memorial Kundiawa General Hospital, Kundiawa, Simbu, Papua New Guinea
  6. 6 Department of Pediatrics, Baylor College of Medicine, Baylor International Pediatric AIDS Initiative, Houston, Texas, USA
  1. Correspondence to Professor Trevor Duke, University Department of Paediatrics, Royal Children’s Hospital, Parkville, Victoria 3052, Australia; trevor.duke{at}


In recent years, most of the focus on improving the quality of paediatric care in low-income countries has been on improving primary care using the Integrated Management of Childhood Illness, and improving triage and emergency treatment in hospitals aimed at reducing deaths in the first 24 hours. There has been little attention paid to improving the quality of care for children with chronic or complex diseases. Children with complicated forms of tuberculosis (TB), including central nervous system and chronic pulmonary TB, provide examples of acute and chronic multisystem paediatric illnesses that commonly present to district-level and second-level referral hospitals in low-income countries. The care of these children requires a holistic clinical and continuous quality improvement approach. This includes timely decisions on the commencement of treatment often when diagnoses are not certain, identification and management of acute respiratory, neurological and nutritional complications, identification and treatment of comorbidities, supportive care, systematic monitoring of treatment and progress, rehabilitation, psychological support, ensuring adherence, and safe transition to community care. New diagnostics and imaging can assist this, but meticulous attention to clinical detail at the bedside and having a clear plan for all aspects of care that is communicated well to staff and families are essential for good outcomes. The care is multidimensional: biomedical, rehabilitative, social and economic, and multidisciplinary: medical, nursing and allied health. In the era of the Sustainable Development Goals, approaches to these dimensions of healthcare are needed within the reach of the poorest people who access district hospitals in low-income countries.

  • tuberculosis
  • quality of care
  • low and middle income countries
  • meningitis
  • chronic lung disease

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  • Contributors TD wrote the first draft; SKT, HP and HW contributed to the ideas presented and made substantial revisions. All authors reviewed and approved the final version of the paper.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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